1

Social Recovery Therapy in improving activity and social outcomes in early psychosis:

current evidence and longer term outcomes

David Fowler1, Jo Hodgekins2*, Paul French3

1University of Sussex, Brighton, UK, BN1 9RH

2Norwich Medical School, University of East Anglia, Norwich, UK, NR4 7TJ.

3University of Manchester, Oxford Road, Manchester, UK, M13 9PL

*Corresponding Author:

Dr Jo Hodgekins

Department of Clinical Psychology

Norwich Medical School

University of East Anglia

Norwich, NR4 7TJ

Email: j.hodgekins@uea.ac.uk

Tel: +44 (0)1603 591890

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ABSTRACT

Background: Social Recovery Therapy (SRT) is a cognitive behavioural therapy which targets

young people with early psychosis who have complex problems associated with severe social

disability. This paper provides a narrative overview of current evidence for SRT and reports

new data on a 2 year follow-up of participants recruited into the Improving Social Recovery

in Early Psychosis (ISREP) trial.

Method: In the ISREP study 50 participants (86%) were followed up at 2 years, 15 months

post treatment. The primary outcome was engagement in paid work, assessed using the Time

Use Survey. Engagement in education and voluntary work were also assessed. In addition, the

Positive and Negative Syndrome Scales (PANSS) and the Beck Hopelessness Scale (BHS) were

administered.

Results: 25% of individuals with non-affective psychosis in the treatment group had engaged

in paid work at some point in the year following the end of therapy, compared with none of

the control group. Data from the PANSS and BHS suggested no worsening of symptoms and

an indication that gains in hope were maintained over the 15 month period following the end

of therapy.

Conclusion: Social Recovery Therapy is a promising psychological intervention which may

improve social recovery in individuals with early psychosis. The new data reported in this

paper shows evidence of gains in engagement in paid employment outcomes that persisted

15 months beyond the period of active intervention.

Keywords: Social Recovery; Psychosis; Cognitive Behaviour Therapy

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1. INTRODUCTION

1.1 Background

Psychosis is the illness of working age adults most frequently associated with poor

outcomes. A review of recovery rates suggests that, despite recent advances in treatment

options, less than 14% of individuals diagnosed with schizophrenia achieve sustained

recovery on both symptomatic and functional outcomes (Jaaskelainen et al., 2013). Social

and functional outcomes from psychosis have received more attention in recent years and

feature in service user definitions of recovery (Law & Morrison, 2014). Social recovery can

be defined in terms of engagement in activities within occupational and interpersonal

domains (Hodgekins et al., 2015). This may include work, education, valued social activities,

and relationships with others. Studies suggest that less than 50% of people with non-

affective psychosis achieve a social recovery (Hafner & an der Heiden, 1999; Harrison et al.,

1996), and only 10-20% of people return to competitive employment despite the majority

suggesting that they wish to work (Mueser et al., 2001). The personal and economic costs

of this disability are large (Fleischhacker et al., 2014). The lives of young people are

disrupted at a crucial stage of development and many continue to struggle over the long

term to achieve key milestones in terms of personal achievement and social roles (Bond et

al., 2014; Kam et al., 2013; Lenior et al., 2001; Wiersma et al., 2000).

1.2 Treating Social Disability in Psychosis

Perhaps unsurprisingly due to their focus on positive psychotic symptoms, pharmacological

treatments for psychosis appear to have no direct effects on functional recovery (Kern et al.,

2009). Indeed, side effects from medication may even hamper activity levels. Early

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Intervention Services have demonstrated some success in improving social outcomes in first

episode psychosis by providing assertive case management and supported employment

interventions (Fowler et al., 2009a; Craig et al., 2014). However, despite provision of such

services, a substantive proportion of cases remain socially disabled (Hodgekins et al.,

2015a). More specific targeting of those individuals showing early signs of delayed social

recovery in first episode psychosis using cognitive behaviour therapy (CBT) may be an

important way to further improve the effectiveness of Early Intervention Services (Fowler et

al., 2010).

A major success of CBT has been on targeted interventions which focus primarily on unitary

disorders and single symptoms. Research trials of CBT for psychosis have shown promising

indications of an impact on social disability where assessed as a secondary outcome. The

systematic review of studies of CBT in psychosis carried out by Wykes et al. (2008) highlights

an effect of CBT on social disability where assessed as a secondary outcome with a mean

effect of 0.38 (15 studies), although social disability was not specifically targeted. The NICE

schizophrenia review (2014) also reports an effect of CBT for psychosis on social functioning.

However, the challenge often faced in complex cases is comorbidity. Young people with

first episode psychosis who do not recover socially often leave work or education and lose

contact with social networks (Killackey et al., 2009; Bond et al., 2015; Kam et al., 2013).

Such individuals often adopt lifestyle patterns of extreme social withdrawal, which typically

occurs in the context of complex comorbid symptoms of paranoia and other positive and

negative psychotic symptoms and frequently also depression, anxiety and other disorders

(Hodgekins et al, 2015a). Alongside such issues are complex social circumstances and

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systemic issues including problematic family dynamics, victimisation, social threat and social

deprivation. The cases at highest risk are the most complex, and a single symptom focused

approach is not sufficient. Clinically, the presentations are complex and therapists can easily

become overwhelmed and hopeless, not knowing where to start.

1.3 Social Recovery Therapy

We have developed a novel CBT intervention called Social Recovery Therapy (SRT; Fowler et

al., 2013). The focus of the intervention is on the individual’s values and goals, identifying

problems and barriers to these, then promoting hope for meaningful behavioural change.

Our approach is to start with a formulation of social recovery from the perspective of the

individual. This provides a clear direction for both therapists and clients faced with what can

seem otherwise an overwhelming clinical scenario. Cognitive techniques are used to

develop a sense of optimism and agency and to build positive beliefs about self and others.

There is a large emphasis on the use of behavioural strategies (including behavioural

experiments, graded exposure and behavioural activation) to overcome avoidance and

promote meaningful behavioural change “in vivo” whilst managing symptoms as necessary

to address a meaningful pathway to social recovery. Evidence and experiences from this

behavioural work are used to further instil hope and promote positive beliefs about self as

the individual works towards achieving meaningful change in their lives.

SRT differs from traditional CBT for psychosis in its largely behavioural focus and emphasis

on building positive beliefs about self and others rather than challenging negative beliefs in

isolation. In addition, to achieve gains in social recovery against a background of often years

of withdrawal and social disadvantage means that therapists have to integrate techniques

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more typically associated with assertive community treatment and supported employment.

Working systemically with families and stakeholders surrounding the individual to promote

opportunities in the social environment is also important.

1.4 Research evidence in support of SRT

To date, we have conducted two single-blind randomised controlled trials of SRT with

individuals with first episode psychosis and social recovery difficulties: the Improving Social

Recovery in Early Psychosis (ISREP) trial (Fowler et al., 2009b) and the Sustaining Positive

Engagement and Recovery (SUPEREDEN) trial (Fowler et al., in press). In both studies, the

primary outcome was hours per week spent in structured activity, assessed using the Time

Use Survey (Hodgekins et al., 2015b).

In the ISREP trial, 77 participants with affective or non-affective psychosis were randomised

to receive either SRT plus Treatment as Usual (SRT + TAU) or TAU alone. TAU consisted of

case management from a secondary mental health care team. We found differential effects

for people with affective and non-affective psychosis. Specifically, in the non-affective

psychosis group, SRT showed significant superiority on the primary outcome of weekly

hours in structured activity. In addition, significant superiority of SRT + TAU over TAU alone

was seen for Positive and Negative Syndrome Scale (PANSS; Kay et al., 1987) scores. There

was an effect of therapy on hopelessness and positive beliefs about self and improvements

on these variables were a mediator of change in the therapy group (Hodgekins et al., 2010).

The intervention was also shown to be cost-effective (Barton et al., 2009).

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The SUPEREDEN3 trial was a larger (N = 154) and more definitive multicentre trial of SRT

conducted as part of a programme of research evaluating UK Early Intervention services

(Birchwood et al., 2014). SUPEREDEN3 tested the efficacy of enhancing social recovery

following first episode psychosis by combining the use of standard Early Intervention Service

(EIS) provision with Social Recovery Therapy (SRT). The primary hypothesis was that SRT in

combination with EIS would lead to improvements in social recovery compared with EIS

alone. Participants were also followed up 6 months after the end of the intervention.

The primary analysis indicated that the SRT + EIS was associated with an average increase in

structured activity of just over 8 hours per week greater than EIS alone (95% CI 2.5 to 13.6;

p = 0.005). A consensus group of clinicians and service users have conservatively estimated

the minimum clinically significant gain on the TUS as 4 hours. The size of the effect in the

SUPEREDEN3 trial is twice this gain and represents an amount of activity equivalent to a

working day. As such, the findings show a clinically important benefit of enhanced social

recovery for the SRT plus EIS group on the primary outcome of structured activity post-

therapy. Modelling of outcomes 6 months after the end of the intervention also showed

promise for the maintenance of therapy gains and improvements in trait hope.

1.5 Long-term outcomes and therapy gains maintenance

Both the ISREP and SUPEREDEN3 trials provide some evidence in support of SRT in

producing clinically significant gains in time spent in structured activity compared to

treatment as usual. There is also a suggestion that this gain may be maintained 6 months

beyond active treatment. However, despite the development of new treatments, studies

have found that long-term functional outcomes following psychosis remain poor

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(Jaaskelainen et al., 2013). Therefore, evidence of longer term outcomes following SRT are

required.

In addition to studying maintenance effects of SRT, a longer follow-up period would enable

further changes in social recovery to be examined. A common goal of individuals taking part

in the ISREP and SUPEREDEN3 trials was to return to work and education. Participants had

often been unemployed for long periods of time prior to being recruited into the study and

thus whilst weekly hours in structured activity improved following the delivery of SRT, it was

anticipated that the full effects of the intervention on engagement in paid work may not be

observed immediately post-intervention. Following the end of the intervention period it was

often noted that participants were in the process of applying for work or educational

programmes but that formal engagement in these activities had not yet commenced. A

longer term follow-up would enable an investigation of whether work and education were

taken up following the end of the intervention.

1.6 Aims and Hypotheses of the Current Study

The current study reports on longer term follow-up data from participants who took part in

the ISREP trial. Participants were followed up 15 months after the end of the intervention

period (2 years following entry into the study) to explore whether or not they had engaged in

work, education or voluntary work following the end of therapy. It was hypothesised that a

greater proportion of the SRT + TAU group would have engaged in work, education or

voluntary work when compared to the group who received TAU alone. Long-term effects of

the intervention on symptoms and hopelessness were also examined as these variables were

found to mediate outcome in the primary post-intervention analyses. Differences in

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outcomes for individuals with affective and non-affective psychosis were explored as the

intervention showed differential effects for these groups post-intervention, with therapy

effects being shown for the non-affective group only.

2. METHOD

2.1 Design

The ISREP trial was a single blind randomised controlled treatment trial comparing SRT in

addition to treatment as usual (SRT + TAU) with those receiving TAU alone. All participants

were receiving care from secondary mental health services and thus TAU involved regular

contacts with mental health professionals, including Case Managers and Psychiatrists.

However, participants in the control arm of the study did not receive any psychological

therapy. See Fowler et al. (2009b) for a full description of the trial. In the current study, trial

participants were followed up 2 years after randomisation had taken place, 15 months after

the end of the intervention period.

2.2 Participants

Inclusion and exclusion criteria and participant characteristics for the ISREP trial have been

described in the trial outcome paper (Fowler et al, 2009b). Seventy-seven participants were

originally recruited into the ISREP study: 35 were randomised to receive SRCBT and 42 were

randomised to receive TAU. Of these, 66 (86%) were followed-up 2 years later: 29 (82.8%) of

the SRCBT group and 37 (88%) of the TAU group. Of those 11 individuals who were not

followed up at 2 years, 6 had dropped out of the study during the intervention period; 2 could

not be contacted, and 3 declined to participate in the follow-up assessment.

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2.3 Measures

2.3.1 Primary Outcome

The presence of paid work, education, and voluntary work occurring at any point in the year

following the end of therapy was screened for using the Time Use Survey (Hodgekins et al.,

2015b; Gershuny et al., 2011). The TUS is a semi-structured interview assessing how

individuals spend their time. Following the interview, work, education, and voluntary work

were coded as being either present or absent in the year following the end of the intervention

period. This assessment can be undertaken by telephone contacts and triangulated with carer

reports as well as from face-to-face interviews, thus maximising available data at follow-up.

Although the TUS can be used to assess engagement in a range of structured activities (e.g.

structured leisure and sports activities, socialising, etc), the focus of the current study was

work, education and voluntary work. Total number of hours spent in paid work over the last

year was also recorded.

2.3.2 Secondary Outcomes

Positive and Negative Syndrome Scale (PANSS; Kay et al., 1987). The PANSS is a 30-

item rating scale developed to assess symptoms associated with psychosis. Symptoms

occurring over the last week were rated. PANSS total scores were used.

Beck Hopelessness Scale (BHS; Beck and Steer, 1988). The BHS is a 20-item self-report

scale designed to assess the way an individual perceives the future. Items are rated using a

dichotomous true/false response format. Total scores from the BHS were used.

2.4 Procedure

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The extended follow-up was not part of the original ISREP trial protocol and thus ethical

approval was sought and granted to recontact and reconsent study participants. Participants

who had consented to take part in the ISREP study were contacted by letter and telephone to

invite them to take part in the follow-up assessment. Following informed consent,

assessments were conducted by trained research assistants who were blind to treatment

allocation. Where possible, assessments were conducted using face-to-face interviews and

this occurred in 75% of cases. However, the primary outcome measure could also be

administered via telephone or discussions with care co-ordinators.

2.5 Statistical Analyses

We first report frequencies for engagement in competitive employment, voluntary work, and

education at 2-year follow-up for participants with affective and non-affective early psychosis

and descriptive statistics for secondary outcomes. Chi-square tests are used to test for any

significant differences in engagement in work, education, and voluntary work between the

treatment and control group. Where the expected count was less than 5 for more than 20%

of the cells, Yates’ corrections were employed.

Analysis of Covariance (ANCOVA) models were used to test the significance of differences on

secondary outcome variables between the treatment and control groups. For each ANCOVA,

outcome at the 2 year follow-up was used as the dependent variable; allocation to treatment,

centre, and diagnosis were used as fixed factors; and three key variables assumed to be

associated with outcome and predictive of drop out were used as covariates (baseline scores

on the dependent variable; baseline schizotypal symptoms score; and length of

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unemployment). Non-significant interactions were removed before final testing for main

effects.

3. RESULTS

Frequency of engagement in work, education, and voluntary work at 2 years are shown in

Table 1. Descriptive statistics for other outcome variables are given in Table 2. These are

broken down by treatment and diagnostic group.

3.1 Engagement in work, education and voluntary work

In the combined sample of individuals with affective and non-affective psychosis, more

individuals in the SRT + TAU group had engaged in paid work over the 15 months since the

end of the intervention period compared to the TAU alone group (31.0% vs. 16%). However,

there were no significant differences between the SRT + TAU and TAU alone groups in terms

of engagement in work, education or voluntary work. The 9 individuals from the SRT + TAU

group who had engaged in work reported having done so for an average of 305.39 hours over

the follow-up period (SD = 334.40 hours, range = 8.0-940.5 hours). Data on hours spent in

paid work was available for 4 of the 6 individuals from the TAU group (mean hours = 265.13,

SD = 105.60, range = 108.0-332.5).

In the non-affective psychosis TAU group, 0 out of 24 participants had engaged in paid

employment in the year following the end of the intervention period, compared with 5 out of

20 (25%) participants in the non-affective psychosis SRT + TAU group. This difference was

found to be significant using a chi-square test with Yates’ correction (expected count <5 in

>20% cells), χ2(1, 44) = 4.52, p = 0.03. The 5 individuals who had engaged in work reported

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having done so for an average of 162 hours over the follow-up period (SD = 128.09 hours,

range = 35-315 hours). There was no difference between the non-affective SRT + TAU and

TAU groups in terms of engagement in education or voluntary work.

There were no significant differences between the SRT + TAU and TAU alone groups for those

with affective psychosis in terms of frequency of engagement in paid work (44.4% vs, 46.2%).

The 4 individuals with affective psychosis from the SRT + TAU group who had engaged in paid

work reported having done so for an average of 484.63 hours (SD = 446.34 hours, range = 8.0-

940.5 hours). Data on hours spent in paid work over the follow-up period was available for 4

of the 6 individuals with affective psychosis from the TAU group (mean = 265.13 hours, SD =

105.60 hours, range = 108.0-332.5 hours). There was no difference between the affective SRT

+ TAU and TAU groups in terms of engagement in education or voluntary work.

3.2 Secondary outcomes

Both the TAU and SRT + TAU groups showed a gradual reduction in symptoms over the study

period. At 2-year follow-up there was a strong trend suggesting an allocation by diagnosis

interaction for hopelessness, with the non-affective psychosis treatment group scoring lower

on the BHS than individuals in the non-affective psychosis control group (F(1,32)=3.39, p =

0.08). However, ANCOVAs revealed no main effects of treatment on symptoms in the total

sample or in the affective or non-affective psychosis subgroups.

4. DISCUSSION

4.1 Summary of findings

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The follow up data for the ISREP trial provide supportive evidence for longer term gains in the

use of SRT in young people with early non-affective psychosis. Fifteen months after the end

of the intervention, 25% of participants in the SRT + TAU group had engaged in paid work

compared to none of the TAU group. In addition to this there was no worsening of symptoms,

despite increased engagement in activity; and there was also a suggestion that improvements

in hope were maintained. Engagement in other types of activity (work and voluntary work)

was equivalent for the SRT + TAU and TAU non-affective psychosis groups with over 50% of

both groups engaging in education and voluntary work. This is positive and suggests that some

improvement in functioning may take place naturally over time. However, in order to meet

longer-term goals in relation to engagement in paid work, targeted intervention is likely to be

necessary.

As with the post-intervention data for ISREP reported by Fowler et al. (2009b), the positive

effects of SRT seem to be specific to individuals with non-affective psychosis, with no

superiority of treatment being shown for the affective psychosis sub-group. Indeed,

individuals with non-affective psychosis demonstrated relatively good outcomes with over

40% engaging in education and voluntary work, irrespective of whether or not they received

treatment. This replicates literature highlighting better outcomes in individuals with bipolar

disorder as compared to individuals with schizophrenia, possibly due to a return to good

functioning between episodes (Martinez-Aran et al., 2007). Individuals with affective

psychosis may also have different barriers to functional recovery which require a different

intervention. However, it must be remembered that the affective psychosis subgroup in this

study was small (n = 22; 13 = TAU, 9 = SRT+TAU) and this impacts upon our ability to draw

definitive conclusions.

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4.2. Adding to the evidence-base for social recovery interventions

This study adds to the growing evidence base for the use of psychological interventions to

target social and functional disability following psychosis (Kern et al., 2009). Other

interventions include supported employment, Social Skills Training, and Cognitive

Remediation. However, whereas other interventions tend to focus on individual barriers to

recovery (e.g. cognitive deficits), SRT uses an individualised formulation combined with

assertive outreach techniques to understand and target a range of barriers and comorbidity.

It is also appropriate for individuals who may be ambivalent about change and who

demonstrate a pattern of disengagement. As such, our study includes individuals who may

not currently be considered suitable for psychological therapy. In addition, SRT differs from

traditional CBT for psychosis due to its wider focus on functioning and an emphasis on the

use of behavioural techniques.

It is difficult to compare the results of the current study with other interventions due to the

use of different outcome measures. A review of supported employment studies in individuals

with first episode psychosis (Bond, Drake & Luciano, 2015) reports an employment rate of

49% for those receiving supported employment interventions compared to 29% of individuals

receiving standard early intervention service provision. Similarly, a meta-analysis of the

international evidence for supported employment for people with severe mental illness

suggests that individuals in receipt of supported employment interventions are more than

twice as likely to find competitive work than those receiving standard care (Modini et al.,

2016). Although the employment rates in the current study are not quite as high as those

from some supported employment trials, it should be remembered that supported

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employment is generally designed for individuals who are motivated to find work. SRT may

be suitable for more chronic and complex cases who may not be ready to engage with

supported employment. Indeed, the rates of employment were very low in the TAU group in

the current study. This suggests that without targeted intervention, such individuals are likely

to remain unemployed and socially disabled. Moreover, some of the reported challenges to

implementing supported employment (Craig et al., 2014), including fears around relapse from

family members and mental health team staff, may be addressed by the systemic components

of our SRT intervention.

4.3 Study limitations

Although all participants in the trial were accessing secondary mental health services and

therefore were in regular contact with mental health professionals as part of TAU, there was

no control condition. Future studies should aim to compare SRT to a control intervention

matched in terms of frequency of contacts and other non-specific factors. It was also not

possible to follow-up all participants who were initially entered into the ISREP study and thus

the effect of drop-out is not known. However, we did manage to follow-up 86% of

participants, which is comparable to many other RCTs (Walters et al., 2017). It would have

been interesting to look at time spent in a broader range of activities, such as structured

leisure and sports activities. Indeed, the TUS was specifically developed to do this. However,

this would have required all participants to have engaged with a face-to-face follow-up

assessment. The decision was taken to focus on a more limited assessment of functioning

which could be assessed via the telephone and from informants in order to maximise follow-

up rates.

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4.4. Conclusions and future research

Overall, evidence for the use of SRT with young people with complex social recovery problems

associated with non-affective psychosis is growing. This is a highly challenging group to work

with who are difficult to engage and present with complex and comorbid difficulties.

However, as cases with the worst prognosis it is highly important to target this group as

otherwise the likelihood is of long term social disability is high. SRT shows good promise. The

SUPEREDEN3 study shows definitive evidence of a gain in activity as a result of treatment at

9 months. Benefits over the longer term are suggestive from modelling of the SUPEREDEN3

study at 6 months post-intervention and from the ISREP follow-up data presented here.

Research has suggested that social disability may precede the onset of psychosis. As such, we

are in the process of conducting a trial of SRT with individuals with At Risk Mental States who

have social recovery problems (PRODIGY trial; Fowler et al., 2017; Notley et al., 2015).

Findings from the PRODIGY trial will suggest whether or not these gains can be replicated in

individuals at an earlier stage of illness. Further research is also necessary to explore whether

SRT could be effective for individuals at a later stage of illness, outside of Early Intervention

Services.

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Figure 1

CONSORT Diagram of Flow of Participants through the Trial

Fully Suitable N = 200

Consented N= 88 Did Not Consent N= 112

Assessed and Randomised N = 77

Dropped out during baseline assessment N=11 Reasons: Symptomatic N= 5 Not interested N= 5 Personal reasons N= 1

Treatment (SRCBT) N = 35 Location: Centre 1 N= 24 Centre 2 N= 11 Diagnosis: Affective N= 12 Non-affective N= 23

Control (TAU) N = 42 Location: Centre 1 N= 26 Centre 2 N= 16 Diagnosis: Affective N= 15 Non-affective N= 27

N = 33 Post-intervention

follow-up (9 month)

2 drop-out 4 drop-out

N = 38

N = 29

N = 37 2-year follow-up 1 drop-out 4 drop-out

25

Table 1

Presence of paid employment, education, and voluntary work in the year following the end

of the intervention period

N (%) engaged in activity p-value

TAU

(N = 37)

CBT

(N = 29)

Paid Work Total sample 6 (16.2) 9 (31.0) 0.15

Non-Affective 0 (0.0) 5 (25.0) 0.03*

Affective 6 (46.2) 4 (44.4) 0.94

Education Total sample 19 (51.4) 11 (38.0) 0.28

Non-Affective 14 (58.3) 10 (50.0) 0.31

Affective 5 (38.5) 1 (11.1) 0.35

Voluntary Work Total sample 17 (46.0) 14 (48.3) 0.55

Non-Affective 12 (50.0) 11 (55.0) 0.11

Affective 5 (38.5) 3 (33.3) 0.84

26

Table 2

Descriptive Statistics – Mean (SD) – by Treatment and Diagnosis

Note. T1 = baseline assessment, T2 = post-treatment (9mths), T3 = 2-year follow-up assessment

Total Sample Non-Affective Affective

TAU SRT+TAU TAU SRT+TAU TAU SRT+TAU

PANSS Total

T1

T2

T3

56.0 (10.3)

50.4 (10.1)

46.7 (12.8)

57.6 (11.6)

50.5 (9.2)

49.0 (12.2)

58.1 (9.4)

53.2 (8.3)

49.3 (11.4)

57.5 (10.8)

50.3 (8.2)

47.1 (11.4)

52.1 (11.0)

44.5 (11.3)

41.4 (14.5)

58.0 (13.4)

50.7 (11.3)

52.6 (13.8)

Beck Hopelessness

Scale

T1

T2

T3

8.7 (5.8)

7.9 (5.8)

6.1 (6.0)

8.9 (5.8)

6.4 (4.7)

6.0 (5.3)

8.0 (5.5)

8.2 (5.9)

6.0 (6.1)

8.3 (5.5)

4.9 (2.3)

4.7 (4.8)

10.2 (6.4)

7.3 (5.9)

6.4 (6.2)

10.2 (6.3)

9.3 (6.6)

9.6 (5.5)